It’s been called the emperor of maladies. It’s been called a civil insurrection of the body. Cancer - a group of diseases (approximately 100 different types) has affected about 90 million people around the world. A significant number of these patients are in India, with the Indian Council for Medical research estimating that about 14 lakh new patients are diagnosed with one form of cancer or other, every year.
Further statistics are also disheartening. According to Dr. Sankar Srinivasan, a Medical Oncologist at the Apollo Cancer Institute, part of the Apollo Hospitals group, a significant portion of those living with cancer in India, are in the productive age group of 40-60 years - at least 10 years younger than the average age of patients in the western world. Of these, very few might seek the medical care and support they deserve, with the ICMR saying that only 12% of the patients who are at risk of cancer, or who may be living with the disease, come to hospitals in the early stage of the disease.
Perhaps one reason for this is the stigma associated with cancer - much higher than the stigma for more deadly conditions such as heart diseases. A second possible reason could be that traditional treatment methods for cancer - Chemotherapy, Radiation, and the like - while effective at controlling cancer, may cause other long-term problems.
Although the science behind chemotherapy has progressed much in the last 100 years, to the extent that it could be done with just a one-day visit to the hospital, those under Chemotherapy may face side effects like hair loss, chronic fatigue and tiredness, pain, loss of appetite and more.
Dr. Sankar Srinivasan is excited about Immunotherapy. And so are other oncologists. With good reason.
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Immunotherapy is cutting edge science in the fight against cancer. “The concept is fairly simple. You get rid of the defence mechanism of the tumour cell,” says Dr. Srinivasan. It allows the oncologist to guide the body’s own immune system to target the cancer cells, and effectively remove them. Each cell in the body has an inbuilt protein called the Programmed Cell Death Protein which regulates the body’s immune system and prevents cells from growing unchecked. Cancer cells have a shield-like mechanism that prevents the programmed cell death protein to activate. In cancer-fighting immunotherapy, Dr. Sankar introduces a drug - the PD1 Inhibitor, that binds itself to the cancer cells, makes the cancer cells more vulnerable, and triggers an immune response. This allows the T-Cells of the immune system to attack and flush out the cancerous cells.
This is a new development, says Dr. Sankar Srinivasan. Immunotherapy for cancer is only about 3-4 years old, although the science has been used for treating diabetes, and some infectious diseases. The big difference is that in diabetes or other conditions, the doctors try and boost the body’s immunity using certain proteins and drugs, but in cancer care, oncologists take away the tumour cells’ inbuilt defence. The science will develop and advance, says Dr. Srinivasan, and “we will have 2nd and 3rd Generation immunotherapy as we go on.”
What can Immunotherapy do to help cancer patients?
The biggest advantage is that this is relatively non-toxic, and is much safer than other, available treatments. Immunotherapy is also able to control the spread of cancer cells from one part of the body to other - a risk that chemotherapy has.
“You don’t have the side effect such as hair loss, decrease in blood count…” says Dr. Sankar.
Immunotherapy was first used to treat skin cancer - melanoma, which is rarer in India than in other countries. But now, the technique is used for other types of cancer, such as head and neck cancers, cancer of the lung or kidneys, breast cancers, lymphoma or blood-cell cancers, colon cancers, and more. A range of malignancies can be treated with immunotherapy, and according to experts, a bulk of cancer patients will be treated with immunotherapy soon. Either in combination with chemotherapy (in advanced cases), or on its own.
Trials are currently on to combine two different kinds of immunotherapy - each of which works slightly differently - which doctors and scientists hope will improve the rate at which cancer cells are killed. In India, Apollo Hospitals in Chennai set up the first corporate hospital in the country to treat cancer, and its speciality Apollo Cancer Institute is one of the few approved, recognized centres for clinical trials of immunotherapy methods. Which means, any global breakthrough in treating cancer, will instantly be available to Indians, through Apollo.
A further advantage for immunotherapy is that it reduces the hospitalisation for patients. A shorter stay, and fewer side effects mean that patients can carry on with their lives and loves, and expect a better quality of life than with other forms of cancer therapy.
But is Immunotherapy entirely safe?
“We cannot call it completely safe, but certainly safer or better than other treatments,” says Dr. Sankar Srinivasan. There are some side effects - mainly associated with the immune system, such as a flare-up of auto-immune diseases, conditions affecting the lung, some skin reactions, and liver abnormalities. “But, side effects are manageable. We see more patients who get immunotherapy and we are also experienced in taking care of those side effects.”
“People are able to continue it for a longer time,” he adds. “A person with extensive cancer, can go on with his or her normal activities, without much progression, for a much longer time.”
“Essentially, we are only heading in this direction”, says Dr. Sankar, at Apollo Hospitals Chennai.
Immunotherapy with PD1 Inhibitors, or Immune Checkpoint Inhibitors, help shrink tumours much faster and to a greater extent than other forms of cancer treatments, and has a higher patient response rate. Studies have showed that patients with advanced Melanoma, or with Non-Small Cell Lung Cancer, have better long-term survival rate with PD1 inhibitor based immunotherapy, than with other traditional cancer therapy such as chemotherapy.
“Cancer immunotherapy has offered an idea and a hope for a hundred years, but you couldn’t go to your doctor’s office and get a successful immunotherapy,” says immunologist Gordon Freeman of Dana-Farber Cancer Institute in Boston, Massachusetts. But that is now changing, with newer drugs like ipilimumab, nivolumab, and other PD1 inhibitors. Dr. Sankar Srinivasan says that these drugs have been in use in US and other western countries since 2007-2008, and in India for the last two years. And Apollo Cancer Institute is one of the earliest users of these drugs.
Dr. Sankar Srinivasan, who is also a visiting consultant at Ironwood cancer research centre, in Phoenix, Arizona, is leading the research from India. His department at Apollo is part of global trials for newer drugs, and is also collaborating with major international institutes. This allows Dr. Srinivasan to keep himself updated of the latest in immunotherapy - and bring global best practices to India.
This offers a “win-win” situation for patients. Those willing to be part of clinical trials, will essentially be administered the same global protocols for disease management, as in advanced countries. Further, globally, clinical trials are paid for by institutions and pharma corporations, and access to global trials come free of cost to patients. The same is true of patients in India, which takes one set of worries off their shoulder. And with Apollo hospitals and Dr. Sankar Srinivasan taking care to ensure that the patient’s specific needs and issues are properly addressed, patients and their families can sit back and breathe a sigh of relief.
Ultimately, we come back to the age old saying. The answer to every problem is within oneself. And cancer immunotherapy is the latest proof.